What is the comprehensive management and prognosis of a 13-year-old male (M) with testicular torsion?

Management and Prognosis of Testicular Torsion in a 13-Year-Old Male

Testicular torsion in a 13-year-old male is a surgical emergency requiring immediate urological consultation and surgical intervention within 6-8 hours of symptom onset to prevent permanent testicular loss. 1

Clinical Presentation and Diagnosis

• Testicular torsion presents with sudden onset of severe scrotal pain, often accompanied by nausea and vomiting, and occurs more frequently in adolescents with a bimodal distribution peaking in neonates and postpubertal boys. 1, 2
• Key physical examination findings include:
  • Red, swollen scrotum with an acutely painful testicle, typically without history of trauma 3
  • Negative Prehn sign (pain not relieved when testicle is elevated) 1, 2
  • Absent cremasteric reflex 4
  • Positive Deming's sign (affected testicle may be positioned higher) 4

Diagnostic Evaluation

• Duplex Doppler ultrasound is the first-line imaging modality with 69-96.8% sensitivity and 87-100% specificity, showing: 1, 2
  • Decreased or absent blood flow to the affected testicle 1
  • "Whirlpool sign" of the twisted spermatic cord (highly specific) 1
  • Enlarged heterogeneous testis that may appear hypoechoic 1
  • Ipsilateral hydrocele and scrotal skin thickening 1, 5
• The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can help with risk stratification: 1
  • High score (>5): Proceed directly to surgery
  • Intermediate score (1-5): Urgent ultrasound
  • Low score (0): Consider alternative diagnoses

Management Algorithm

1. Immediate urological consultation upon suspicion of testicular torsion 1, 2
2. Manual detorsion attempt may be performed while awaiting surgical intervention, but does not replace the need for surgery 3
3. Emergency surgical exploration within 6-8 hours of symptom onset: 1, 2, 4
   • If the testicle is viable: Detorsion and bilateral orchidopexy
   • If the testicle is necrotic: Orchiectomy of the affected side and contralateral orchidopexy
4. Post-operative care: Bed rest, scrotal elevation, and analgesics until inflammation subsides 1

Prognosis

• Testicular salvage rates are directly related to the time between symptom onset and surgical intervention: 1, 3, 6
  • Within 6 hours: >90% salvage rate
  • 6-12 hours: 50-70% salvage rate

  • 12 hours: <10% salvage rate

• Adolescents under 18 years have been shown to present with longer delays (median 20 hours vs. 4 hours in adults), resulting in higher orchiectomy rates (44% vs. 8%) 6
• Even with successful salvage, there may be long-term concerns about testicular function and fertility 7

Common Pitfalls and Caveats

• Misdiagnosis as epididymitis is common, but epididymitis typically has a more gradual onset and positive Prehn sign 1, 2
• Partial torsion or spontaneous detorsion can result in false-negative Doppler evaluations 1
• Atypical presentations with intermittent pain may delay diagnosis, as seen in mesorchial torsion 5
• Clinical presentations of testicular torsion, epididymitis, and torsion of testicular appendage can overlap, making accurate diagnosis challenging 2
• Age-related delay in seeking medical attention significantly impacts outcomes in adolescents 6

Differential Diagnosis

• Epididymitis/epididymo-orchitis: Most common in adults, gradual onset, positive Prehn sign 1, 2
• Torsion of testicular appendage: Most common in prepubertal boys, may present with "blue dot sign" 1, 2
• Other considerations: Strangulated inguinal hernia, traumatic hematoma, testicular tumor, or testicular fracture 3